Myoma is known as a benign (benign) tumor in the female reproductive system that often affects the uterus (uterus). It originates from the smooth muscle of the woman’s uterus. Chickpeas can be encountered in sizes ranging from small structures the size of a hazelnut to the size of an orange, quince or even a soccer ball, and rarely in giant sizes that fill the entire internal cavity of the abdomen.
This can occur in approximately 70-80% of women of reproductive age, considering the things that pass unnoticed and without causing any distress to women due to their different sizes. Generally, in the reproductive age period, it can be detected in a small size that is not noticed at all in one of every 4-5 women at the age of 30-40, or in noticeable sizes. Myoma tends to shrink after menopause. As a result, the patient’s symptoms decrease. Pre-existing fibroids grow in size during pregnancy. Myoma can be found as a single structure in the uterus (uterus), or it can be in many numbers and in different localizations. This common table Uterine myomatosis is called. In many operations, as I have come across in my own practice, tens of small to large myomas can be removed.
Myoma is more than 99% benign. although it may develop some different symptoms and signs. For example; rapid growth in follow-up, advanced age groups, some special MRI findings and structure It can show changes for Sarcoma, albeit at a very low rate (malignant transformation).
Causes of fibroidsWhen examined, it is not very clear in terms of familial predisposition. geneticThis tendency is also common in the reproductive age, due to the shrinkage of post-menopausal structures. steroid hormones, especially estrogen hormoneis focused on.
Localization of fibroids in different parts of the uterine wall makes their approach different as well as their symptoms.
Photograph-1 and 2As can be seen in the following section, fibroids can be in different numbers and in different localizations of the uterine wall.
single giant fibroid
Intrauterine with handle
Fibroids can be found in different sizes and localizations. Different classifications have been made by different scientific associations according to the location and size of this settlement. These classifications are useful in determining both the symptoms of myoma and the treatment methods to be applied to them. In the Diagram-1 below, the localization of myomas in the uterus and their naming (Myoma Classifications) are shown.
Diagram-1: Localization of myomas in the uterus and naming according to them (Myoma Classifications)
This diagram has been modified from the Uterine Leiomyoma (fibroid) Classification System (Illustration) from the internet.
Explanations of medical words in the diagram:
intramural: Inside the uterine wall, Submucosal:Uterine inner wall =under the mucosa, subserosal: Outer surface of the uterus = under the mucous membrane, pedicel: with handle
Since fibroids can be in different localizations from person to person, in some cases, they are different in terms of their location and size. they may not cause any symptoms.
Symptoms generally seen due to fibroids; dense and irregular bleedingperiods, lower abdomen (pelvic region) compressions or ache, problems with getting pregnant, in cases of pregnancy, it is related to recurrent pregnancy losses, premature birth (premature birth) etc. are problems.
Changes in menstrual bleeding are usually manifested as bleeding over 7 days, exceeding the usual amount, and coming at frequent intervals. Periods of up to 12 days may be encountered in heavy bleeding. In some bleeding cases, the patient may feel pain.
In some cases, although the amount of bleeding is not high, bleeding that continues in the form of long-term drips between menstruation may be encountered. The first application sites of some cases developed as a result of blood loss. anemia There may be internal medicine departments due to (anemia). One of the biggest causes of recurrent bleeding and ongoing anemia that cannot be corrected with treatments is myoma-related bleeding.
Although there is controversy among other problems related to fibroids, most observational studies support it. reproductive system dysfunctions.(infertility = infertility, recurrent pregnancy loss, etc.). Myoma-related painIt is also possible to call it as those with menstrual period and non-menstrual pains.
By the size of myoma and the region where it is located pressure on surrounding organs may also give symptoms associated with it. Especially in the growth of the uterus (womb) in the anterior neighborhood, the urinary bladder ( bladder)with the pressure frequent urinationor the desire to urinate again before the bladder is fully emptied or in advanced pressures extreme difficulties in urinatingIn addition, fibroids in the posterior regions of the uterus in a neighborhood relationship can be seen due to intestinal pressure. defecation difficulties(constipation = constipation) problems may occur.
Still pain in the back and legs due to size and nerve compressioncan also be encountered.
Risk factors that may cause fibroids:
Myoma generally forms the uterine wall and It is considered to originate from the smooth muscle muscle known as the myometrium. . As a result of the proliferation of stem cells (stem cell) in this region by dividing and multiplying with the effect of different factors, this new formation in the myometrium, which has a harder structure compared to it, does not have a true capsule (peudo capsule = pseudo capsule) (non-cancerous) growth is known and observed.
Pathologically, myomas are caused by the region where they develop. fibroma, leiomyomaThey also take their names.
in pregnancy There may be changes in the growth structure of myoma under increased blood supply and hormonal effects. ( red degeneration=carnous degeneration)
after menopauseshrinkage in the size of myomas and calcifications in their internal structures can be seen.
Among the factors affecting the formation of myoma genetic tendencies There is an increased chance of fibroids in those who have a family history of fibroids in their mothers and sisters. Apart from this, one of the most frequently held responsible effects of estrogen and progesterone hormonesAs the biggest evidence of this, although myoma cases are frequently encountered in the reproductive age, as mentioned above, after menopause, due to the withdrawal of hormones from the environment, the fibroids shrink.
Considering the distribution of myoma cases more common in blacksseen, early menstruationin those who have been under hormonal effects for many years, more than the Mediterranean diet (vegetable-fruit) those who consume red meat, alcoholIt has been determined that more myomas are found in those who consume more. Less birth control pillsIt has also been reported that fibroids can be seen.
In the diagnosis of myoma, first of all, the menstrual period ( menstruation, bleeding) historyIt should be learned from which symptoms, especially the patient’s, is the problem. physical examinationMyoma borders can also be detected by palpation of the abdomen.
However, the most reliable form of inspection Classical Pelvic ExaminationObstetrics and Gynecologist’s 2 fingers are in the vagina and the fingers of the other hand are on the abdomen of the patient ( bimanual examination ) is. In this examination, the doctor can evaluate the uterus by feeling the ovaries around it and the internal female organs of the tubes. Fibroid(s) are structures that can be evaluated (palpable) differently from the uterus with their hard structure/s.
Uterus = Uterus
This figure has been taken from the internet, modified from Mayo Clinic Q and A: October 19, 2018.
In the treatment of myoma cases, the patient’s desire for a child gains importance.
Fertility=whether there is a desire for fertility, the age of the patient, the growth and changes in the structure of the myoma in the follow-up of myoma, the localization of myoma and the symptoms it creates in other organs, anemia=anemia that is unresponsive to treatments and cannot be corrected, and the general condition of the case are the issues that should be evaluated in the treatment approach.
A-Approach to cases with a desire for fertility:
Myoma localizations gain importance among approaches in this regard.
1- If myoma is only in the inner layer of the uterus (submucous myoma): Surgical approach:
In most of this group, irregular and sometimes heavy bleeding and anemia are seen. After evaluating the case and excluding other diseases of the uterus (different diseases of the cervix and the inside of the uterus, etc.) Myomectomy by hysteroscopic route (removal of myoma) operation is performed. See Hysteroscopy, one of the author’s articles on this subject.)
Hysteroscopic myomectomy: It is the process of entering the uterus with an operative hysteroscope and seeing the uterine inner layer myoma on the television screen in a very short period of time and removing the structure from the cervix by shaving the structure with special cutting systems in the hysteroscope (hysteroscopic resection).
As you can see from Diagram-1, Myomas 0 and 1 are completelyeven in the uterine wall as far as it can be reached Some of myomas no. 2 are also cleared with this surgical procedure. . This approach is a surgical approach that is usually short-lived under general anesthesia. The patient received full treatment under normal conditions and has the luxury of being discharged on the same day.
Intrauterine excluding fibroids polypsSimilar operations are performed for the removal of the spleen.
2-Myomas located outside the uterus. Surgical approach:
As can be seen from diagram-1, which is close to the inner uterine cavity but where hysteroscopic approach is not possible, localization No:2 myomasand other localizations No:3-7 myomasThe approach for Abdominal Myomectomyis . myomectomyIn operations, only the fibroids/fibroids are removed from the uterine wall by leaving the uterus.
Removal of myoma with abdominal surgery (Abdominal myomectomy) operation, either by opening the abdomen = classic laparotomyvia the laparoscopic route ( standard laparoscopy or robotic laparoscopy) is myomectomy.
Today, myoma localization, myoma size, myoma structure, operator experience laparoscopic myomectomyis the preferred approach . The only troublesome issue of laparoscopic myomectomy today is how to remove the fibroid from the abdominal cavity after the fibroid has been successfully removed from the uterine wall. Opinions on this subject will be explained to the patient in detail by the doctor who will perform the surgery and the operation will be decided after the consent form is obtained from him.
The ideal size for the laparoscopic approach is that the size of myoma is smaller than the size of 17 weeks of pregnancy (4 months + 1 week). Which method will be applied in the case is a matter that should be discussed with the doctor and the case should be evaluated in terms of possible side effects. However, in terms of possible side effects, the subject may return to the classical abdominal approach as a result of the discussion of the doctor and his case.
After the operation, an intervention will be planned for pregnancy in the uterus left behind. In some cases, if there are cases where the removal of large fibroids or the removal of many fibroids may cause more damage to the remaining uterus than expected, this situation will be reported to the patient before the operation. In these conditions, although not in all centers and in some countries, it does not have a clear common practice. uterine artery embolization( UAE ), focused ultrasound surgery ( MRgFUS) methods can be applied.
If there are no myoma symptoms in cases with fibroids who will attempt pregnancy and the only problem of the case is infertility, should surgery be performed even when there is no problem with myoma? The question is an important one. 6 months for <35 years old, in order to save time for the group where myoma is at 16 weeks (4 months) gestational age, and
If there is no pregnancy at the end of this period, myoma treatment should be decided by waiting for 3 months for those aged > 35 years, after all fertility evaluations and possible approaches are made in this time period.
Approach to the case in the presence of both submucous and other uterine wall fibroids:
It requires the combination of two separate surgeries. In these cases, an approach is planned with hysteroscopy for intrauterine and abdominal/laparoscopic methods for others.
3- Wait-follow method for treatment in myoma cases: Expectant treatment?
These cases are followed up at regular intervals, usually at intervals of 3-4 months, in terms of the size of myoma and the presence of bleeding symptoms or new symptoms. Each time the case is seen, the course of myoma is determined by determining the history, physical and pelvic examination, ultrasound evaluation, and laboratory findings.
This follow-up follow-up, known as expectant therapy, is generally symptomless, in cases attempting pregnancy, in those whose fibroid follow-up can be followed without changing over the years, in those who are in the menopausal period or after menopause, and in the follow-ups where the size of the uterus with myoma is smaller than 3 months (12 weeks) gestational week, or in other words. With this method, fibroids that can not be noticed manually on the abdomen can be followed up with this method.
B- Approach to myomas in cases without fertility desire:
Myoma-related anemia deep anemia symptom takes priority in the approach . Permanent treatment approach especially for the anemic case: Myoma localization and size and if there is no other inconvenience in the surgical application; For fibroids of the submucous region (for a part of type 0, type 1 and mostly type 2 fibroids)) gold treatment Resection of myoma with hysteroscopic approach = It is the removal of the fibroid from the cervical opening by reducing it with incisions. This way ( Hysteroscopic myomectomy ) myoma and its related symptoms will be eliminated. In this application, which has a success rate of around 85-95% and is performed in a short time under general anesthesia, the patient is usually discharged on the same day.
From submucous fibroids >5cmthe size of the uterine wall or from the uterine cavity >50%occupying more than in type-2 fibroids (See Diagram-1), either extraction may not be possible in the same session, or a small amount of fibroid residue (residue) may remain in the uterine cavity after the operation. This information and possibilities should be discussed with the patient before the operation. In some cases, a second session approach may be required.
Approach to fibroids with symptoms other than submucous fibroids:
The approach can be determined as medical or surgical approaches within the doctor’s evaluation. Some alternative treatment methods can also be offered to the cases.
1-Medical treatments for fibroids with symptoms other than submucous fibroids:
The treatments that can be used in cases with blood loss, pain, compression symptoms and who want to be excluded from the surgical approach or who are medically at the limit of the surgical approach will be mentioned below by name. The doctor will make treatment and follow-up by sharing the most appropriate one for the case and the ones that will not cause any trouble in the use of the case and possible side effects.
Medical (medical treatments):
Combined birth control pills (estrogen + progestin) they contain. These combinations can also be applied using a vaginal ring or skin-adhesive veils (transdermal patch).
Intrauterine devices that release the hormone progestin.(LGN IUD)
progestin aloneContraceptives, implants or injections containing
Estradiol+norethindrone acetate combinations(Elagolix-FDA 2020 approved)
GnRH analogs and GnRH antagonists
note: Developed in Europe and once recommended as a medical treatment for fibroids. Ulipristal (UPA) mifepritone Although they were seen as beneficial for myoma-related anemia, these drugs without FDA approval are not recommended for use today. In particular, UPA is far from its old popularity due to serious liver toxicity, liver transplantation in a few cases, and even death, and has a usage problem.
2-Surgical treatments for fibroids with symptoms other than submucous fibroids:
In patients who were at the border in terms of surgery before, but medical treatment was tried but was not successful due to the circumstances of the case, and in cases with initial levels of cervix, intrauterine diseases, uterine prolapse which is the cause of symptoms in the case, which may require other treatment and follow-up related to the uterus=uterus other than myoma or myoma localization Due to their size and size, the approach can be planned surgically.
Classic surgical approach for myoma cases: Hysterectomy and Myomectomycan be collected under headings.
hysterectomy In , there is complete removal of the uterus. The case will not only get rid of fibroids and its related symptoms, but will also get rid of benign irregular bleeding of the inner layers of the uterus or changes in the cervix that may cause problems in the future.
Hysterectomy by opening the abdomen classic (Abdominal hysterectomy) or vaginally ( vaginal hysterectomy) as well as the localization of myoma, its size and the surgical experience of the doctor. classic Laparoscopic Hysterectomyor Robotic laparoscopic Hysterectomycan be done as well.
Removal or release of the ovaries (ovaries) and tubes together during hysterectomy:
This is the age of the case, family history of ovarian cancer, the presence of findings related to possible problems in the examination of the ovaries, and the doctor’s approach. The general approach is to protect the ovaries, except for the case history and the BRCA1 and BRCA2 values, which are mutation markers at high risk for breast and ovarian cancer, or the possibility of a pathology that can be considered in the ovary. This issue should be well evaluated on a case-by-case basis. Because the cases whose ovaries and tubes were removed during hysterectomy (hysterectomy + bilateral salpingooopherectomy = BSO) will stay away from ovarian functions (hormonal estrogen and progesterone deficiency) and may experience a surgical menopause.
If myomectomy operation is The purpose is to leave the uterus and only the removal of fibroids. Sarcoma? Myomectomy is preferred in cases without symptoms.
Although myoma is mostly a benign tumor of the uterus, it is found in the ratios of 1/2000 to 1/500 or 1/352 in case studies of hysterectomy or myomectomy. cancerization of a sarcoma nature shown. Other than this change of myoma, completely benign changes (degenerations) can also be encountered. These are hyaline, cystic, carnous (change with bleeding in myoma during pregnancy), calcific (increased calcification in myoma seen in menopausal women), septic (infection inside myoma).
It is correct to wait 3 months to consider a new pregnancy after myomectomy. Again, the doctor’s decision, the number of fibroids removed in myomectomy, their size and their effects on the uterus can be evaluated, and a cesarean delivery can be made in a new pregnancy after myomectomy. In the approach to fibroids encountered during cesarean section in general, the option of simultaneous myomectomy should be considered last, considering the bleeding problem.
3- Non-medical and non-surgical methods in myoma treatment: Alternative fibroid treatments:
Here, applications on this subject will be given as titles. Since these methods depend on technology development products, they are alternative applications that are not available in every center and their transportation brings economic difficulties, but should be known.
UAE(Uterine Artery Embolization),
MRgFUS(Magnetic Resonance imaging Focusedhigh intesity Ultrasound)=( Focused ultrasound surgery)
Myoma + pregnancy :
The probability of pregnancy + myoma can vary between 1.6-10.7% . In most of the myoma cases, no problem is encountered, but in 1/3 of the fibroids, growth can be seen in the first trimester (first 3 months), especially in the first 10 weeks. This growth is due to increased estrogen levels during pregnancy.
Problems may be encountered in 10% to 30% of myoma + pregnancy cases. The most common symptom in pregnancy + myoma cases ache is. Generally, problems are experienced in cases with myomas larger than 5 cm and in the last 2 trimesters of the case (pregnancy periods after the first 3 months).
This approach to problems can range from simple to complex situations . The case should be evaluated well and kept under close follow-up. simple approach; rest cureadequate fluid support ( hydration), can use during pregnancy mild pain relieversIt is a treatment approach that relieves the mother’s complaints with the use of an analgesic.
Much discussed during pregnancy. complicated approachif myomectomy and it is an initiative that has to be done according to the decision of + and – to evaluate the case well. Because the operation may pose risks to the fetus. For this reason, myomectomy in the second half of pregnancy should be a decision to be considered in detail.
Effects of myomum on pregnancy;
abortions(nearly doubled.) Developmental delay in baby(due to its effect on infant development areas in large fibroids), Separation of placenta from its region, premature birth(due to contractions in the uterine muscles in cases with pain), especially localization and size of myoma in myoma cases The rate of termination of pregnancies by cesarean section has increased 6 times.Depending on the area change in the intrauterine structure of the fibroid, breech arrivals increased.This means mandatory cesarean section for these cases.
Conclusion : Myoma, which is seen in approximately one of 4-5 women of reproductive age, is a benign uterine tumor, but it is a problem that degrades women’s life in terms of its symptoms. Since medical or surgical approaches, which will be well evaluated by a doctor who has experience in this field, can solve the problem, following up the cases at the beginning of the event should be the first step of the treatment attempt.